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0121 661 2921
Sheldon, Birmingham
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Submit a Referral Form
This form allows dental professionals to refer patients to White Pearl Dental Practice for consultation or specialist treatment. Please complete all relevant sections to ensure smooth and accurate clinical handover.
Referring Dentist Information
Referring Dentist Name
Practice Name
Contact Name
Phone
Patient Information
Patient Full Name
Date of Birth
Address
Phone
Email
Preferred Contact Method
Area of Concern
Left Top
1
2
3
4
5
6
7
8
Left Bottom
1
2
3
4
5
6
7
8
Right Top
1
2
3
4
5
6
7
8
Right Bottom
1
2
3
4
5
6
7
8
Referral Request Type
Consultation only
Consultation & treatment
Is this a re-treatment?
Has root canal treatment already been started?
If yes, when?
A film is being:
Emailed
No film
Patient has been put on:
Antibiotics
Pain Medication
If meds have been prescribed, please list:
Level of Discomfort
None
Mild
Moderate
Severe
Cold sensitive
Heat sensitive
Pressure sensitive
Throbbing pain
Facial swelling
Additional comments:
Submit
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Opening Hours
Monday: 9:00 AM – 5:00 PM
Tuesday: 9:00 AM – 5:00 PM
Wednesday: 9:00 AM – 7:00PM
Thursday: 9:00 AM – 5:00 PM
Friday: 9:00 AM – 2:00 PM
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